The proposed study is designed to reduce racial disparities in HIV treatment outcomes by developing and pilot-testing a Motivational Interviewing intervention to support patient decision-making about antiretroviral therapy (ART) initiation and to enhance motivation to begin ART. Antiretroviral therapy has dramatically extended the lives and reduced the suffering of people with HIV, but many clinically eligible patients refuse ART. Others stop ART without notifying their medical providers. Although adherence to ART has been extensively studied, much less is known about factors which lead patients to accept or reject ART altogether. Our preliminary studies indicate that many patients are ambivalent about ART, and that cognitive factors such as a belief in HIV conspiracy theories and mistrust of the medical system may contribute to reluctance to initiate or continue ART. We propose to develop an intervention grounded in cognitive theory which primarily uses Motivational Interviewing techniques to weaken belief barriers and reduce ambivalence about ART initiation. The population of interest is inner-city African- Americans with HIV who are not currently receiving ART and are suboptimally engaged in care. The intervention will be tested both in an HIV outpatient clinic setting and an AIDS Service Organization (ASO) setting. Community advisors and expert consultants will contribute to the development and iterative refinement of the intervention protocol. The protocol will be tested first in a small uncontrolled case series (n=10), and then in a larger randomized pilot (n=80) designed to allow preliminary tests of the intervention's effects on key attitudinal measures (perceived barriers to ART, motivation to begin treatment), appropriate HIV medical care utilization, and ART initiation compared to an attention-only control. Institutional barriers to implementing the intervention in the outpatient clinic and ASO settings will be identified and addressed. If the preliminary tests of the intervention provide positive results, then a larger R01 study with a randomized controlled trial design is planned, using the intervention manual developed in the present proposed study. This project is highly innovative in its focus on HIV conspiracy beliefs and its target of ART initiation. PUBLIC HEALTH RELEVANCE: HIV conspiracy beliefs are widespread among African-Americans with HIV, and there is significant reason to believe that these beliefs negatively affect treatment outcomes by contributing to antiretroviral therapy (ART) refusal, delay, or nonadherence. The proposed research will develop a brief intervention to improve rates of ART initiation among African-Americans with HIV by addressing conspiracy beliefs and other cognitive barriers to ART use. If successful, it has the potential to decrease racial disparities in HIV treatment outcomes and improve health and survival for African-Americans living with HIV.